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Monopolar Transurethral resection of bladder tumor (TURBT) has been a gold standard for bladder tumor. Initial studies of bipolar TURBT were promising, however, no high level evidence exists and its exact role remains undefined. We compared the safety and efficacy of bipolar and monopolar TURBT. Primary objective was to compare the incidence of obturator jerk. The secondary objectives included the comparison of decrease in hemoglobin, recoagulation and transfusion requirements, bladder perforation, decrease in sodium, resection syndrome and resection time, hospital stay, detrusor muscle identification and severe cautery artifact in resected specimen in two groups. A randomized control trial was conducted for one year. All patients undergoing TURBT for suspected bladder tumors were eligible. Patient’s refusal to participate, unfitness for spinal anesthesia and lack of tumor in lateral wall were excluded. Of the 118 TURBT done during study period, 48 were excluded and 70 patients, 36 in monopolar and 34 in bipolar arms, were analyzed. The incidence of obturator jerk was less in bipolar arm but not significantly different (26.4% vs. 47.2%, p=0.073). There was no significance difference in most of the secondary outcomes except lesser hemoglobin drop (0.49gm/dl vs. 0.98gm/dl, p=0.016) and lesser resection time in bipolar arm (33.0 mins vs. 46.8mins, p=0.008). Bipolar was not different to monopolar TURBT with respect obturator jerk and most of the secondary outcomes. However, with bipolar TURBT, there was significantly less resection time and although hemoglobin drop was less as well, it was not clinically significant.

IntroductionLaparoscopic donor nephrectomy is the gold standard for kidney retrieval in live donors. Until recently,donor nephrectomies were performed only by open technique in Nepal. There is no information on theexperience and outcomes of laparoscopic donor nephrectomy in Nepal. The study was done to comparethe outcomes among donors undergoing open and laparoscopic nephrectomies, and to compare the graft related outcomes between the two groups receiving these kidneys.MethodsIn this retrospective study, 44 kidney donors from March 2019 to October 2019 were analyzed. Donors were divided into 2 groups: open donor nephrectomy (ODN) and laparoscopic donor nephrectomy (LDN).Parameters for analysis included demographic data, warm ischemia time, surgery time and length ofhospital stay. Data on early graft function and complications in recipients till 30th post-operative day were compared.ResultsThere were 22 donors each in the ODN and LDN groups. Baseline characteristics of the donors were comparable between two groups. Mean surgery duration (183.55±43.31 minutes vs 117.73±18.75 minutes) and first warm ischemia time (11.22±4.34 minutes vs 2.3±0.8 minutes) was significantly high in LDN. Hemoglobin drop, post-operative complications in donors, creatinine of donors at discharge, mean hospital stay, graft function at one month and complications in recipients were comparable among ODN and LDN. Pain score in 1st post-operative day was comparable between two groups, however, pain was significantly less in second post-operative day in LDN.ConclusionLaparoscopic donor nephrectomy is feasible in Nepal and associated with acceptable morbidity and graft function when compared to ODN.Keywords: Laparoscopic donor nephrectomy, open donor nephrectomy, renal transplantation

Renal metastasis from osteosarcoma is a rare entity, and tumour thrombus is even rarer. To date, only 15 cases of osteosarcoma with tumour thrombus have been reported in the literature. We present a case of an 18-year-old female diagnosed as having right distal femur osteosarcoma, later presenting with renal osteosarcoma with IVC thrombus.

PURPOSE This study was aimed to compare lymphatic complications of bipolar vessel sealing system with silk ligation of lymphatic vessels among renal transplant recipients. METHODS This was a prospective randomized controlled trial done among 68 patients undergoing renal transplantation in Tribhuvan University Teaching Hospital. They were randomly assigned to either silk ligation or Enseal bipolar vessel sealing lymphatic dissection. Postoperative drain volume and duration of drain placement were measured in all patients. Ultrasound was used to find lymphocele formation in six and 12 weeks. RESULTS Total of 30 patients in silk ligation group and 28 patients in bipolar vessel sealing group were analyzed. The baseline characteristics of the patients in each group were similar. Overall, lymphatic complications (either lymphorrhea or lymphocele formation) were in 16 cases (27.58%), 7 (25%) in the bipolar group, and 9 (30%) in the silk ligation group (p = 0.67). A total of 13 patients (22.41%) had lymphorrhea, 6 (21.4%) patients in the bipolar group, and 7 (23.3%) patients in the silk ligation group. Median drain volume was 415 ml (Q1 275 ml, Q3 675 ml) in the bipolar group and 542 ml (Q1 290, Q3 775) in silk group (p = 0.72). Median drain removal day was 5 in each bipolar and silk group with Q1 and Q3 being 5 days in each arm (p = 0.95). A total of five patients (8.62%) developed symptomatic lymphocele, two (7.1%) in the bipolar group, and three (10%) in the silk ligation group, but the difference was not statistically significant. In univariate analysis, double renal arteries in the donor's kidney (p = 0.03) and graft rejection (p = 0.04) were risk factors for the development of lymphatic complications. However, in multivariable analysis, these factors were not statistically significant. CONCLUSIONS This study did not find any significant differences in lymphatic complications between bipolar vessel sealing system and silk ligation. However, large sample multi-centric studies should be done to add evidences on lymphatic complications differences between these two techniques. TRIAL REGISTRATION NUMBER UMIN000039354, Date of registration-2020, Feb 01.

Highlights • Myxoid liposarcoma is a rare mesenchymal tumor of the bladder with only a few cases reported in the literature. • It is difficult to diagnose and carries a poor prognosis. • The primary treatment is complete surgical resection which is usually followed by adjuvant chemotherapy. • We report a case of 26 year female with mesenchymal tumor of the bladder presenting as a large abdominal mass., Introduction Myxoid liposarcoma of the bladder is a rare mesenchymal tumor which is difficult to diagnose and carries a poor prognosis. The primary treatment is complete surgical resection which is usually followed by adjuvant chemotherapy. Presentation of case We report a case of 26 years female who presented with a large abdominal mass and was initially misdiagnosed to be arising from ovaries and subsequently discovered to be a mesenchymal tumor arising from the bladder. Discussion Myxoid liposarcoma is an exceedingly rare but aggressive mesenchymal tumor of the bladder often with misleading imaging appearances. Conclusion Surgical resection, when feasible, plays the leading role in its management, and should be attempted in all potential patients.

To define the clinical and pathological patterns of urinary bladder carcinoma from the University Hospital of Nepal. This is a retrospective analytical study. Patients with bladder mass who underwent surgery over 1 year and who had data record were included in the study. Demographic profile, type of surgery, findings on clinical examination, cystoscopy findings, histopathological report, tumor stage, and post-surgery adjuvant therapy were analyzed. Out of 86 patients who underwent transurethral resection of bladder tumor, 77 patients had biopsy-proven malignant bladder tumor. Urothelial cancer was present in 96.1%. Male were 78.6%. The mean age of diagnosis was 65.5 ± 11.8 years. Non-muscle-invasive bladder cancer (NMIBC) was 3.7 times more common than muscle-invasive bladder cancer (MIBC). High-grade tumors (58.6%) were more common than low grade (41.4%). The detrusor muscle was present inthe biopsy specimen of 48 patients (64%). Re-TURBT within 2–6 weeks was considered based on histopathology reports for about half of the patients (45.3%). Upstaging and upgrading of the tumor was present in 5.8 and 5.8% of the patients, respectively. Residual tumor without upstaging and upgrading was present in 23.5%. One patient (1.3%) had Clavien–Dindo grade 1, three (4%) patients had grade 2 and two patients (2.7%) had grade 3b. In the present study, patients with bladder cancer are younger than reported in other studies. Smokers are strongly predisposed. The histological pattern is similar to the Western and Asian populations. NMIBC and MIBC occur in proportion to that described as in other studies. We had a lower rate of recurrence, upstaging and upgrading. We had a lesser rate of acceptance for radical cystectomy in our patients.

Gestational choriocarcinoma with kidney and lung metastases with delayed presentation after term pregnancy is rare event and not described frequently in literature. We describe a rare case of 24-year-old female with hematuria after 3 years of term delivery. Management includes chemotherapy and even renal embolization in case of life threatening hematuria.

Highlights • Atrial fibrillation is associated with peripheral embolism. • Renal artery embolism is reported in rare instances. • Clinical suspicion in high risk patient and urgent treatment is key to success., Introduction Renal artery embolism is uncommon cause of flank or back pain. Of all embolic episodes in patients with atrial fibrillation, 2–4% are renal artery embolism. Early thrombolysis within 90 min has favorable renal outcome. Long term anticoagulation can prevent recurrent embolic episodes. Two different embolic phenomenon within short span in same patient is not described in literature. Presentation of case We describe fifty-year-old female with rheumatic heart disease with atrial fibrillation presented as renal segmental artery emboli with popliteal artery emboli within seven-day interval. Discussion Embolic phenomenon is well known in atrial fibrillation. High index of suspicion in patient with risk factors of thromboembolism with appropriate use of contrast enhanced computed tomography can help early diagnosis. Renal artery embolism is managed with anticoagulation or thrombolysis based on duration of presentation. Peripheral artery embolism can be diagnosed with Doppler ultrasonography. Thrombus can be removed with endovascular procedure or open surgical technique. Holistic patient management includes cardiac workup and treatment of factors predisposing to embolization. Conclusion Early identification and urgent treatment is key to the management of embolic episode in patient with atrial fibrillation. Long term prophylaxis can prevent further episodes.

Introduction: Nephron-sparing surgery (NSS) is the standard of care for clinical T1 (cT1), renal mass less than 7 cm, whenever intervention is indicated. It has ontological outcome equivalent to radical nephrectomy in small renal masses and it also minimizes the progression to chronic kidney disease. However, there is paucity of data on outcomes of NSS in Nepalese population. Methods: A six years retrospective review of medical records of patients undergoing partial nephrectomy from Jan 2012 to Dec 2017 in Department of Urology and Kidney Transplant Surgery at Tribhuvan University Teaching Hospital was done to determine its demographics and outcomes. Results: Twenty eight patients underwent nephron sparing surgery for clinical T1 renal masses in the past six years. Complications occurred in three cases. Five of the lesions were benign and 23 malignant on final histology. Clear cell carcinoma was the commonest variant of renal cell cancer. Margin was positive in two cases and both were kept in close surveillance. There was no local recurrence and renal impairment during five to 60 months follow up. Conclusion: Nephron sparing surgery is a safe procedure with good oncological outcome for clinical T1 renal mass. It prevents unnecessary nephrectomy in benign lesions as well as chronic renal impairment at the same time.

IntroductionAdrenal gland surgery is a challenging art as it encompasses diverse physiological derangements which are evenlife-threatening. Also, it remains a medical finesse to rightly identify the correct patient who will benefit fromsurgery which include strong biochemical and radiological resource. Soundly performed surgery will lead tooncologic and homeostatic correction leading to near normal course.MethodsThis is a retrospective analysis of adrenalectomy cohort over three years in a tertiary center in Nepal identifyingdiagnosis, perioperative management and postoperative course. The objective of this study is to review thepresentation, histopathology and clinical outcomes of patients operated for adrenal mass in our center.ResultsThere were 42 surgeries performed via open approach. The number of adenoma, phaeochromocytoma, carcinomaand non-functioning tumor were 13, 16, 12 and one respectively. In most of the hypertensive patients, controlwas achieved with minimal drug and recurrences were observed in 25% of carcinoma in postoperative follow up.ConclusionA large proportion of operative adrenal mass are observed clinically in our setup. The surgical outcome issatisfactory but judicious perioperative management is essential.KeywordsAdrenalectomy, adrenocortical carcinoma, phaeochromocytoma

Aim: The aim of the study was to evaluate the outcomes of upside-down transplanted kidney with single-suture single-knot technique.Methods: From August 2013 till date, a total of 299 living-related kidney transplantations were done in the Department of Urology and Kidney Transplantation Surgery TU Teaching Hospital and Grande International Hospital, Kathmandu, Nepal. Out of them, 71 upside-down kidney transplantations were performed using single-suture single-knot technique. In this study, their overall outcome is evaluated. Results: Our study showed no difference in the overall outcome between upside-down and standard kidney transplantation and even less blood transfusion rate in upside-down group. Conclusion: There should be no hesitation to perform the upside-down kidney transplantation.

Introduction. Urolithiasis is one of the common disorder with which about 1/5th is found in the ureter, of which 2/3rd is seen in the lower ureter. Medical expulsive therapy is one of the routine modalities of treatment which uses various drugs acting on the ureter smooth muscle by different mechanism. We aim to compare the efficacy of combination vs. single drug. Methods. This randomized controlled trial was done in 176 consecutive patients over a period of six months (March 2019 to August 2019) in Department of Urology and Kidney Transplant Surgery, Tribhuvan University Teaching. Participants were divided into two groups (Group A, tamsulosin plus tadalafil, and Group B, tamsulosin) from computer-generated random numbers. Therapy was continued for a maximum of 3 weeks. Stone expulsion rate, time to stone expulsion, analgesic use, number of colic and emergency room visits for pain, early intervention, and adverse effects of drugs were recorded. Results. Among 176 patients who were enrolled in study, 7 were lost to follow-up, and 5 people required immediate intervention. There was a significant higher stone passage rate in group A than group B (64 vs. 50; P=0.025) and shorter expulsion time (1.66 vs. 2.32 weeks P=0.001) and less number of emergency room visits and colic episodes. No significant side effects were noted during study. Conclusion. Tamsulosin plus Tadalafil is more effective than tamsulosin with early passage of stone and decreased number of colic episodes and emergency visits without significant side effects for lower ureteric calculi of 5 mm to 10 mm.

Persistent Mullerian duct syndrome (PMDS) is a rare entity of internal male pseudohermaphroditism. Transverse testicular ectopia (TTE) is the condition in which one testis moves to the other side and both testes pass the same inguinal canal. The combination of PMDS with TTE is rarer. Here, we present a case a phenotype male with left inguinal hernia and right undescended testis. On exploration of left inguinal region, uterus like tissue with its tubal structures were found. Both testes were in same side, one in left inguinal region and the other in the left scrotum.

Introduction: Exit strategy at the end of percutaneous nephrolithotomy (PCNL) differs from center to center and patient to patient. Standard PCNL has been practiced so far with minor postoperative morbidities. Tubeless PCNL, which obviates most of the nephrostomy related morbidities, has been challenged for its safety. So this study was conducted to compare the safety and morbidity of tubeless PCNL with standard PCNL. Methods: Patients who had undergone PCNL, were randomized into group 1 (standard) and group 2 (tubeless) using computer generated random table. In group 1, nephrostomy tube was placed at the end of the procedure and tubes were omitted in group 2 patients. All preoperative, intraoperative and postoperative parameters were recorded and compared in between the groups. Results: Ninety six PCNLs were randomized into group 1 (47 patients) and group 2 (49 patients). Patients’ characteristics including age, sex, comorbidities, preoperative parameters, size and number of stones and mean operation time were comparable in between the groups. The incidence of postoperative fever, pain and analgesic requirement and urinary leak were found more in group 1 patients. The incidence of postoperative complications and events were comparable in both the groups except for blood transfusion. The mean length of postoperative hospital stay for patients in group 2 was significantly low as compared to group 1. Conclusion: Tubeless PCNL is safe and has less morbidity as compared to standard PCNL in selected cases.

Comparison of Guy’s Stone Score and S.T.O.N.E Nephrolithometry Score for Predicting Outcome of Percutaneous Nephrolithotomy

Pheochromocytoma associated with inferior vena cava (IVC) thrombosis is very rare. A 27-year-old female presented with right flank pain and hypertensive urgency. Contrast-enhanced CT abdomen and gadolinium-contrast MRI abdomen revealed right adrenal mass suspicious of malignancy with invasion and compression to the right IVC wall along with IVC thrombus extending from the level of renal veins to the level of confluence with hepatic veins. Her routine laboratory investigations including 24-hour urine fractionated metanephrines, vanillylmandelic acid, and cortisol were normal. Right adrenalectomy with IVC thrombectomy was done. Perioperative period was uneventful. Histopathology of the mass turned out to be pheochromocytoma with thrombus revealing fibroadipose tissue with fibrin. Pheochromocytoma may present with IVC thrombus as well as normal serum and urinary markers. Thus, clinical suspicion is imperative in perioperative management of adrenal mass.

Histoplasmosis is an opportunistic infection caused by a dimorphic fungus Histoplasma capsulatum. Histoplasmosis causing bilateral adrenal involvement is rare and usually occurs only in immunocompromised individuals with disseminated disease. Here we report a case of bilateral adrenal histoplasmosis with disseminated disease in an immunocompetent patient.